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<meta name="description" content="读书笔记，感谢作者。指在翻瓣和去除部分牙槽骨以后从牙槽窝内拔除患牙的方法。如果遵循一些外科技术的基本原则的话，是全科牙医能够完成。适应症：①患牙有一些异常的牙根解剖形态。最好是手术拔除，避免断根，牙槽骨骨折等情况的发生。②有牙根牙骨质增生(hypercementosis)的患牙，表现为巨大的球状根。③根尖弯曲的患牙。④有融合根(ankylosed roots)或解剖异常的患牙，如牙中牙（dens">
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<meta property="og:description" content="读书笔记，感谢作者。指在翻瓣和去除部分牙槽骨以后从牙槽窝内拔除患牙的方法。如果遵循一些外科技术的基本原则的话，是全科牙医能够完成。适应症：①患牙有一些异常的牙根解剖形态。最好是手术拔除，避免断根，牙槽骨骨折等情况的发生。②有牙根牙骨质增生(hypercementosis)的患牙，表现为巨大的球状根。③根尖弯曲的患牙。④有融合根(ankylosed roots)或解剖异常的患牙，如牙中牙（dens">
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        <p>读书笔记，感谢作者。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0013-ssby/01.jpg"><br>指在翻瓣和去除部分牙槽骨以后从牙槽窝内拔除患牙的方法。如果遵循一些外科技术的基本原则的话，是全科牙医能够完成。<br>适应症：<br>①患牙有一些异常的牙根解剖形态。最好是手术拔除，避免断根，牙槽骨骨折等情况的发生。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0013-ssby/02.jpg"><br>②有牙根牙骨质增生(hypercementosis)的患牙，表现为巨大的球状根。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0013-ssby/03.jpg"><br>③根尖弯曲的患牙。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0013-ssby/04.jpg"><br>④有融合根(ankylosed roots)或解剖异常的患牙，如牙中牙（dens in dente）。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0013-ssby/05.jpg"><br>⑤阻生牙或半阻生牙（impacted and semi-impacted teeth）。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0013-ssby/06.jpg"><br>⑥与邻牙融合的患牙或者与邻牙根尖融合的患牙。如果在这些病例上应用常规拔牙技术，部分牙槽骨可能骨折或者在拔牙的时候跟着拔除的牙根一起被带出。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0013-ssby/07.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0013-ssby/08.jpg"><br>⑦断根在牙槽骨内，涉及溶骨性病损，或者在一些位置，可能会给义齿修复带来问题。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0013-ssby/09.jpg"><br>⑧上颌后牙，牙根被包括在上颌窦内。当上颌窦延伸到上颌牙的根尖区，这些区域的牙槽骨十分脆弱，这增加了上颌结节骨折的风险。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0013-ssby/10.jpg"><br>⑨龈线以下的残根，不能用其它方法拔除的。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0013-ssby/11.jpg"><br>⑩有根尖周病损的残根，不能通过搔刮清除的。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0013-ssby/12.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0013-ssby/13.jpg"><br>⑪乳磨牙牙根环抱着前磨牙，如果常规拔除，容易导致恒前磨牙损伤。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0013-ssby/14.jpg"><br>⑫后牙移位（supraeruption）。当对颌牙缺失的时候，这些患牙会移动很大的一个角度，伴随着对牙槽骨的牵拉的过程。这些患牙必须用外科手术来拔除。<br>禁忌症：<br>无症状的根尖折断，牙髓是有活力的，其在牙槽窝里的深度较深。这种残根的拔除不应当考虑，尤其对于老年患者。①有出现局部并发症的风险，如把牙根推入上颌窦或者损伤下牙槽神经，颏神经(mental nerve)或舌神经。②需要去除很大的一块牙槽骨。③目前有很多健康问题的患者。<br>外科拔牙的步骤：<br>①切开翻瓣。<br>②去骨，暴露牙根的合适范围。<br>③用牙挺或根尖挺或牙钳拔除患牙。<br>④术后对创面的处理及缝合。<br>分为有完整牙冠，只有牙根，以及只有根尖的情况，各有其特点。<br>牙冠完整的患牙的外科拔除<br>1.拔除多根牙<br>为避免并发症，有时拔牙冠完整的单根或多根牙的时候需要采用外科拔牙法。当拔牙涉及上颌多根牙，用信封瓣(envelope flap），颊腭侧用球钻去骨，到达根分叉区域。用裂钻磨出一个凹槽后将颊侧两牙根分根，将牙冠连带腭根一起拔出，然后再分别取出剩下的两个牙根，常使用直挺或者根尖钳。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0013-ssby/15.jpg"><br> 2.拔除根尖区有牙骨质增生的完整牙齿<br>必须用外科拔牙法了。断根是无法避免的。<br>如果是单根，用L形瓣开始，把覆盖在牙根颊侧的牙槽骨去除，然后就可以使用牙钳或牙挺轻松的将没有牙槽骨覆盖的牙齿拔除。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0013-ssby/16.jpg"><br>如果是多根牙，采用信封瓣，颊侧去骨到根分叉区域，分根，用裂钻在牙冠上制造一个垂直的凹槽，并延伸到牙槽间隔的牙槽骨(intraradicluar bone）。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0013-ssby/17.jpg"><br>之后，近中部分首先开始使用牙钳或者牙挺移动（牙根和牙冠）。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0013-ssby/18.jpg"><br>之后，用球钻去除牙槽间隔的牙槽骨，牙槽窝沿着牙根的长度扩大。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0013-ssby/19.jpg"><br>之后，含有增生牙骨质的远中根，就可以很容易的使用牙钳，直挺或者T形挺拔除。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0013-ssby/20.jpg"><br> 间断缝合。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0013-ssby/21.jpg"><br>3.拔除牙根环抱恒前磨牙的乳磨牙<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0013-ssby/22.jpg"><br>这种情况必须使用外科拔除。使用信封瓣并且颊侧用球钻去骨到根分叉区域。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0013-ssby/23.jpg"><br>用裂钻在牙冠上制造垂直的深凹槽分根，使用牙钳首先拔除远中根，然后再拔除近中根。间断缝合伤口。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0013-ssby/24.jpg"><br>4.拔除融合牙(Ankylosed tooth）<br>尤其是伴有牙本质发育不良(dental dysplasia)的患牙，用简单拔牙法有大片颊侧牙槽骨骨折的风险。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0013-ssby/25.jpg"><br>拔除方法：用三角瓣，牙根周围的颊侧牙槽骨用球钻去骨。用骨凿(chisel)，小心的将牙齿连同其与牙槽骨融合的部分一起拔出。缝合。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0013-ssby/26.jpg"><br>外科拔除牙根<br>外科拔除牙根的技术：①颊侧部分去骨以拔除颊侧牙根；②颊侧牙槽骨开窗，以便从牙槽窝或者从开窗处拔除牙根；③颊侧少量去骨后在牙根表面制造凹槽（用来作为挺的支点位置）；④在牙根和牙槽骨之间制造凹槽，以为用挺提供位置。<br>1.在颊侧部分去骨以后拔除残根。<br>单根牙，在牙槽嵴边缘以下。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0013-ssby/27.jpg"><br>使用L形切口（注意是在距离要拔的牙位一颗牙的位置切开），翻瓣。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0013-ssby/28.jpg"><br>颊侧去除大部分牙槽骨，直到牙根大部分暴露。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0013-ssby/29.jpg"><br>使用直挺平行于龈沟拔除残根。使用旋转力和很小的向外的力，牙根很容易移动。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0013-ssby/30.jpg"><br>在修整了牙槽骨边缘以后，用生理盐水冲洗手术区域，复位瓣，缝合。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0013-ssby/31.jpg"><br>患牙有双根，都在牙槽嵴边缘以下，牙根没有分开的情况。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0013-ssby/32.jpg"><br>采用信封瓣，范围为待拔牙临近的一颗牙到两颗牙的区域。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0013-ssby/33.jpg"><br>颊侧用球钻部分去骨直到根分叉区域。用裂钻分根，用直挺拔除。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0013-ssby/34.jpg"><br>清理牙槽窝，缝合。<br>2.颊侧牙槽骨开窗拔除残根。<br>在断根以后即时取出牙根。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0013-ssby/35.jpg"><br>这时颊侧骨板还是完整的。做L形切口，翻瓣，用球钻开窗。这个过程中用生理盐水不断冲洗颊侧牙槽骨，开窗位置由断根的根尖决定。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0013-ssby/36.jpg"><br>扩大窗口，使其足以暴露牙根，使得可以从开窗处伸入一个窄的有角度的牙挺可以让其移动。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0013-ssby/37.jpg"><br>最后处理术区，缝合。<br>牙根也可以直接从开窗区域取出。根据病例情况，用三角瓣或半月形瓣，暴露牙根。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0013-ssby/38.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0013-ssby/39.jpg"><br>之后牙根可以容易的从骨缺损处取出，常用一个窄的有角度的牙挺。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0013-ssby/40.jpg"><br>这种技术常用于折断的很小的牙根，拔牙时没有拔出，在牙槽窝内很长时间，几乎完全被牙槽骨覆盖。<br>3.在颊侧去除少量牙槽骨后，在牙根表面制造凹槽。<br>用于残根在牙槽嵴边缘下方的患牙。用信封瓣，颊侧少量去骨，暴露部分牙根。在牙根上制造凹槽，为双角挺(double-angled elevator）的挺刃提供位置，再用适当的向外的力拔除牙根。主要用于下颌，因为下颌颊侧骨板较厚，可以作为用挺的支点。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0013-ssby/41.jpg"><br>4.在牙根与牙槽骨之间制造凹槽，便于牙挺进入<br>该技术主要用于下颌后牙，因为其颊侧牙槽骨较厚，较硬，有外斜线(external oblique ridge)。用信封瓣，翻瓣后用球钻在颊侧牙槽骨和牙根间制造凹槽，使挺有足够的空间。然后用三角挺(T-shaped elevator)或者Seldin挺放入凹槽内，向上挺牙根，用外斜线做支点。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0013-ssby/42.jpg"><br>外科拔除根尖<br>当牙根断在牙槽窝内很深的时候使用。牙医必须特别关注断根进入上颌窦的情况。当牙根或根尖进入上颌窦时，必须及时处理。为了避免这种情况，拔任何上颌后牙之前，必须用影像学检查小心测量牙根距上颌窦底的距离有多近。尤其是根尖距离上颌窦底较近或者根尖病损与上颌窦底有接触的情况。取断根的时候如果用力不是很轻柔，或者不是用特别的窄的器械的话，牙根很容易进入上颌窦的。<br>当牙根进入上颌窦以后，要及时告知患者，改变手术方案，改约时间同期取出牙根并封闭穿孔的上颌窦。如果牙医没有能力完成手术，要转诊至外科专家处。<br>手术过程：首先用影像学检查准确定位上颌窦内牙根尖的位置。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0013-ssby/43.jpg"><br>做直切口，从尖牙区域开始，以梯形结束，包括拔牙后的牙槽窝。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0013-ssby/44.jpg"><br>翻瓣，在颊侧骨板上开窗，找到进入上颌窦的通路。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0013-ssby/45.jpg"><br>用手术刀切开上颌窦粘膜，观察上颌窦内情况确定牙根位置，用强吸或者牙钳取出牙根。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0013-ssby/46.jpg"><br>如果在瘘管区域有肉芽组织，用刮匙从开窗处和牙槽窝内刮除。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0013-ssby/47.jpg"><br>在取出牙根以后，立即关闭上颌窦穿孔。扩展已存在的梯形瓣，用一个位于瓣的中部和末端的水平切口扩展瓣，以使其足够覆盖穿孔处。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0013-ssby/48.jpg"><br>平滑创口的骨边缘，将瓣与腭侧粘膜对位缝合。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0013-ssby/49.jpg"><br>术后应用广谱抗生素，鼻粘膜应用防止充血剂（0.1%丁苄唑啉xylometazoline喷雾或溶液）一周。10天后拆线，2个月后复查。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0013-ssby/50.jpg"><br>总结一下吧。<br>外科手术拔牙主要就是需要翻瓣和去骨的拔牙方法。核心思想还是先解除阻力再拔牙。主要用于牙根有异常，牙根弯曲，龈下的残根，阻生牙，以及牙根进入上颌窦等情况。平时见得最多的就是残根和弯根。我之前极少用手术方法拔牙（除了阻生牙），都是不管什么情况打了麻药就开始用挺子硬挺，一方面是觉得这样不用动刀损伤小，另一方面也是最主要的还是对切开，翻瓣，缝合等外科基础操作比较陌生，比较恐惧，又不去学习，于是就躲。但是经常的情况是拔一个残根拔一两个小时，拔多根牙残根或死髓牙不知道分根，结果往往一挺就碎，或者一挺就断根，然后就慢慢掏根吧。倒是多数时候都掏出来了，但是患者受的罪以及我费的时间和精力往往远远比翻瓣去骨等方法还要大得多。以后还是要注意。另外，翻瓣去骨缝合等操作，想学种植啥的都是必须的，拔牙的时候就是最好的练习机会。</p>
<p>我发文章的三个地方，欢迎大家在朋友圈等地方分享，欢迎点“在看”。<br>我的个人博客地址：<a href="https://zwdnet.github.io/">https://zwdnet.github.io</a><br>我的知乎文章地址： <a target="_blank" rel="noopener" href="https://www.zhihu.com/people/zhao-you-min/posts">https://www.zhihu.com/people/zhao-you-min/posts</a><br>我的微信个人订阅号：赵瑜敏的口腔医学学习园地<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/other/wx.jpg"></p>

      
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